Eduardo Borquez
Gillian Lieberman, MD
September 2002
Radiological Diagnosis and
Treatment of Pulmonary
Embolism
Eduardo Borquez, Harvard Medical School Year III
Gillian Lieberman, MD
Eduardo Borquez
Gillian Lieberman, MD
Presentation Overview
I.
II.
III.
IV.
Patient Summary
Disease Introduction
Radiologic Diagnosis
Radiologic Treatment
2
Eduardo Borquez
Gillian Lieberman, MD
I. Patient Summary
z
z
S.I. 54 y/o ♂
Hx:- chronic + acute lower extremity DVT
- atrial flutter
- brain abscess 2° to dental procedure
Tx w/ craniotomy June 2002
Index case courtesy of Matthew Spencer, MD
3
Eduardo Borquez
Gillian Lieberman, MD
Patient Summary
z
HPI: -↓mobility following craniotomy
- SOB w/ dyspnea on exertion of 4 days
duration prior to admission
z
PE: - Afebrile, BP 136/96, HR 107, RR 18
- O2Sat 95% on room air.
- Well appearing, but mild distress.
- Cardiopulmonary: tachycardia, clear lungs.
- Dark ecchymosis and tenderness on L ant. Thigh
- Palpable clot in R popliteal fossa.
Index case courtesy of Matthew Spencer, MD
4
Eduardo Borquez
Gillian Lieberman, MD
Patient Summary
z Diagnosis:
– USÆ R+L popliteal vein DVT
– CXR noncontributory
– CT revealed heavy PE burden
– Angiogram
z Treatment
– Thrombectomy
Index case courtesy of Matthew Spencer, MD
5
Eduardo Borquez
Gillian Lieberman, MD
II. Disease Introduction
Incidence
300,000 Diagnosed, 50,000 deaths annually. (200,000 deaths
according to Robbin’s). Estimated 600,000 undiagnosed annually.
Etiology
Virchow’s triad (injury, stasis, hypercoag.). DVT: 90% arise from
large deep veins of lower legs.
Signs/Sx
Dyspnea, plueritic pain, cough, hemoptysis.
Tachypnea, rales, tachycardia.
Diagnosis
Hx/PE, CXR, ABG, ECG, Hemodynamics, V/Q scan, CT, Angio.
Pathology
↑ vascular pressure (blocked flow/ vasospasm), ischemia.
Surgery/ Tx
Medical and Mechanical (Radiologic and Surgical) thrombolysis,
embolectomy and secondary prevention.
Prognosis
Without tx: 30% mortality. With effective tx: 2-8% mortality.
Thompson BT, Hales, CA UpToDate Clinical manifestations of and diagnostic strategies for acute
pulmonary embolism http://www.utdol.com
Tapson, VF, UpToDate Massive pulmonary embolism http://www.utdol.com
Cotran: Robbins Pathologic Basis of Disease, 6th ed., Copyright 1999 W. B. Saunders Company
6
Eduardo Borquez
Gillian Lieberman, MD
Difficulty in Diagnosis
Symptom
PE %
No PE %
Dyspnea
73
72
Pleuritic pain
77
59
Cough
43
36
Leg swelling
33
22
Leg pain
30
24
Hemoptysis
15
8
Palpitations
12
18
Wheezing
10
11
Angina-like pain
5
6
Stein, PD et al, Clinical, Laboratory, Roentgenographic and Electrocardiographic findings in patients
with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. Chest 100(3):598.
7
Eduardo Borquez
Gillian Lieberman, MD
Difficulty in Diagnosis
Signs
PE %
No PE %
Tachypnea
70
68
Crackles
51
40
Tachycardia (>100)
30
24
4th heart sound
24
14
↑P2
23
13
Deep venous thrombosis
11
11
Diaphoresis
11
8
Temp. > 38.5 C
7
12
Wheezes
5
8
Right ventricular lift
4
2
Pleural friction rub
3
2
3rd heart sound
3
4
Cyanosis
1
2
Stein, PD et al, Clinical, Laboratory, Roentgenographic and Electrocardiographic findings in patients
with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. Chest 100(3):598.
8
Eduardo Borquez
Gillian Lieberman, MD
III. Radiologic Diagnosis
A. Chest X-Ray
B. Ventilation-Perfusion scan
C. CT with contrast
D. Angiography
E. Ancillary tests: Doppler US
9
Eduardo Borquez
Gillian Lieberman, MD
A. CXR
1. Classic Findings
z
z
z
z
z
z
Atelectasis
Pleural effusion
Parenchymal opacification
Elevation of hemidiaphragm
Hampton’s Hump (wedge
shaped pleural-based
triangular opacity with apex
pointing toward hilus.
Westermark’s sign
(decreased vascularity).
Garg, K. CT of Pulmonary Thromboembolic disease. Radiologic Clinics of North America 40(1); 2002
Felson, B. Gamuts in Radiology. 2nd Edition
10
Eduardo Borquez
Gillian Lieberman, MD
A. CXR
1. Classic Findings
z
z
z
z
z
z
Atelectasis
Pleural effusion
Parenchymal opacification
Elevation of hemidiaphragm
Hampton’s Hump (wedge
shaped pleural-based
triangular opacity with apex
pointing toward hilus.
Westermark’s sign
(decreased vascularity).
Differential
1.
Bronchial adenoma
2.
Bronchiectasis
3.
Carcinoma, bronchogenic
4.
Compression atelectasis
5.
Contraction atelectasis
(fibrosis)
6.
Foreign body
7.
Mucus plugs
Garg, K. CT of Pulmonary Thromboembolic disease. Radiologic Clinics of North America 40(1); 2002
Felson, B. Gamuts in Radiology. 2nd Edition
11
Eduardo Borquez
Gillian Lieberman, MD
A. CXR
1. Classic Findings
z
z
z
z
z
z
Atelectasis
Pleural effusion
Parenchymal opacification
Elevation of hemidiaphragm
Hampton’s Hump (wedge
shaped pleural-based
triangular opacity with apex
pointing toward hilus.
Westermark’s sign
(decreased vascularity).
Differential
1.
Abscess
2.
Ascites
3.
Collagen disease
4.
Infection
5.
Lymphoma
6.
Metastasis
7.
Pancreatitis
8.
Trauma
Garg, K. CT of Pulmonary Thromboembolic disease. Radiologic Clinics of North America 40(1); 2002
Felson, B. Gamuts in Radiology. 2nd Edition
12
Eduardo Borquez
Gillian Lieberman, MD
A. CXR
1. Classic Findings
z
z
z
z
z
z
Atelectasis
Pleural effusion
Parenchymal opacification
Elevation of hemidiaphragm
Hampton’s Hump (wedge
shaped pleural-based
triangular opacity with apex
pointing toward hilus.
Westermark’s sign
(decreased vascularity).
Differential
1.
Atelectasis
2.
Consolidation (ex. pneumonia)
3.
Pleural Effusion
4.
Pneumonectomy
Garg, K. CT of Pulmonary Thromboembolic disease. Radiologic Clinics of North America 40(1); 2002
Felson, B. Gamuts in Radiology. 2nd Edition
13
Eduardo Borquez
Gillian Lieberman, MD
A. CXR
1. Classic Findings
z
z
z
z
z
z
Atelectasis
Pleural effusion
Parenchymal opacification
Elevation of hemidiaphragm
Hampton’s Hump (wedge
shaped pleural-based
triangular opacity with apex
pointing toward hilus.
Westermark’s sign
(decreased vascularity).
Differential
1.
Atelectasis
2.
Distended stomach or spleen
3.
Rib fracture (guarding)
4.
Phrenic nerve paralysis
5.
Pleural disease
6.
Pneumonia
7.
Postoperative
8.
Ruptured liver or spleen
9.
Scoliosis
Garg, K. CT of Pulmonary Thromboembolic disease. Radiologic Clinics of North America 40(1); 2002
Felson, B. Gamuts in Radiology. 2nd Edition
14
Eduardo Borquez
Gillian Lieberman, MD
CXR findings patients with no previous
cardiac or pulmonary disease
Finding
PE %
No PE %
1) Atelectasis
66
48
2) Pleural effusion
48
31
3) Pleural based opacity
35
21
4) Elevated diaphragm
24
19
5) Decreased vascularity
21
12
6) Prominent central pulmonary artery
15
11
7) Cardiomegaly
12
11
8) Westermark’s sign (defined as 4 and 5 above)
7
2
9) Pulmonary edema
4
13
Stein, PD et al, Clinical, Laboratory, Roentgenographic and Electrocardiographic findings in patients
with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. Chest 100(3):598.
15
Eduardo Borquez
Gillian Lieberman, MD
CXR S.I.: Normal Findings
S. I. 6-25-02 Comparison film
BIDMC PACS
S.I. 8-8-02
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Eduardo Borquez
Gillian Lieberman, MD
CXR
z CXR
is usually nonspecific for PE
z Value is in excluding other diagnosis that
may mimic PE and in interpreting V/Q scan
Thompson BT, Hales, CA UpToDate Clinical manifestations of and diagnostic strategies for acute
pulmonary embolism http://www.utdol.com
Tapson, VF, UpToDate Massive pulmonary embolism http://www.utdol.com
Worsley, DF et al Chest Radiographic Findings in Patients with Acute Pulmonary
Embolism: Observations from the PIOPED Study. Radiology 189:133-136. 1993
17
Eduardo Borquez
Gillian Lieberman, MD
Ventilation/Perfusion Scan
1. Procedure
Æ Technetium (Tc) 99m or Xenon aerosol
Æ Tc-99m macroaggregated albumin
Æ Take different views.
Worsley, DF, et al. Radionuclide Imaging of Acute Pulmonary Embolism. Radiologic
Clinics of North America 39(5). 2001
18
Eduardo Borquez
Gillian Lieberman, MD
Ventilation/Perfusion Scan
2. An example of a normal Scan (not our patient S. I.)
Perfusion
RAO
ANT
LPO
POST
LAO
RPO
LL
RL
Ventilation
19
Image courtesy of Dr. Kevin Donohoe
Eduardo Borquez
Gillian Lieberman, MD
Ventilation/Perfusion Scan
2. An example of a high probability scan
(not our patient S.I.)
Perfusion
Defects
Perfusion
Ventilation
20
Image courtesy of Dr. Kevin Donohoe
Eduardo Borquez
Gillian Lieberman, MD
V/Q: Normal vs. Abnormal
Cardiac border
Perfusion Defects
Diaphragmatic border
Example of a normal scan
Example of a high
probability scan
21
Image courtesy of Dr. Kevin Donohoe
Eduardo Borquez
Gillian Lieberman, MD
Ventilation/Perfusion Scan
3. Pitfalls and advantages
- Bronchospasm
+ Physiologic
- Pneumonia
+ Can visualize past 4th
generation vessels
- Poor circulation
+ Future in GPIIb/III
receptor imaging
- Logistics
- Non-radiologist bias
Worsley, DF, et al. Radionuclide Imaging of Acute Pulmonary Embolism. Radiologic
Clinics of North America 39(5). 2001
22
Eduardo Borquez
Gillian Lieberman, MD
Ventilation/Perfusion Scan
4. Interpretation continued
Clinical Science Probability %
Scan Category
High
(80-100)
Intermediate
(20-79)
Low
0-19
High probability
96
88
56
Intermediate
66
28
16
Low
40
16
4
Near
normal/normal
0
6
2
PIOPED Investigators. Value of the Ventilation/Perfusion Scan in Acute
Pulmonary Embolism. JAMA 263(20):2753. 1990
23
Eduardo Borquez
Gillian Lieberman, MD
CT with Contrast
+
Directly shows emboli
Non-invasive
High sensitivity for central
vessels (near 100) but low for
segmental (53-91)
Relatively cheap
Info about alternative diagnosis
“One-stop” imaging for DVT and PE
Garg, K. CT of Pulmonary Thromboembolic disease. Radiologic Clinics of North America 40(1);
2002
24
Eduardo Borquez
Gillian Lieberman, MD
CT Anatomy
A brief orientation for the CT scans of our patient S.I.
Ribs
T5 Intervertebral disk
25
http://www9.biostr.washington.edu/da.html
Eduardo Borquez
Gillian Lieberman, MD
CT Anatomy
Superior vena cava
Ascending and descending aorta
26
http://www9.biostr.washington.edu/da.html
Eduardo Borquez
Gillian Lieberman, MD
CT anatomy
Right pulmonary artery
Pulmonary trunk
http://www9.biostr.washington.edu/da.html
Left pulmonary artery
27
Eduardo Borquez
Gillian Lieberman, MD
CT Anatomy
Intermediate and left principle bronchi
28
http://www9.biostr.washington.edu/da.html
Eduardo Borquez
Gillian Lieberman, MD
CT S.I. Findings
Emboli
BIDMC PACS
29
Eduardo Borquez
Gillian Lieberman, MD
Angiogram
z Gold
standard
z Iodinated contrast injected into the
pulmonary artery
z Positive result consists of filling defect or
sharp cutoff.
z Mortality ~0.5% Morbidity ~5%
Thompson BT, Hales, CA UpToDate Clinical manifestations of and diagnostic strategies for acute
pulmonary embolism http://www.utdol.com
Tapson, VF, UpToDate Massive pulmonary embolism http://www.utdol.com
30
Eduardo Borquez
Gillian Lieberman, MD
Angiogram Anatomy
31
http://www9.biostr.washington.edu/da.html
Eduardo Borquez
Gillian Lieberman, MD
S.I. Findings
Right
Left
Clot in upper
lobe vessels
Clot in L main
Free floating clot
in proximal R
descending
pulmonary artery
Clot in lower
lobe vessels
2 globular
clots which fill
nearly the
entire
descending
pulmonary
artery
32
http://www9.biostr.washington.edu/da.html
Eduardo Borquez
Gillian Lieberman, MD
Angiogram S.I. Findings
Upper Lobe Vessel
Embolus
S. I.
BIDMC PACS
Proximal R
descending clot
Normal
33
Eduardo Borquez
Gillian Lieberman, MD
Angiogram S.I. Findings
Left Main Embolus
S.I
BIDMC PACS
Left descending
Normal
34
Eduardo Borquez
Gillian Lieberman, MD
Algorithms
Decision making can
be complex and
many algorithms and
neural networks have
been developed.
This is an example of
a simple, radiology
centered algorithm.
Garg, K. CT of Pulmonary Thromboembolic disease. Radiologic Clinics of North America 40(1);
2002
35
Eduardo Borquez
Gillian Lieberman, MD
IV. Radiologic Treatment
A. Treatment Overview
B. Radiologic Treatment
36
Eduardo Borquez
Gillian Lieberman, MD
A. Treatment Overview
Medical
Primary Treatment
Secondary Prevention
Thrombolysis
Unfractionated heparin
LMW heparin
IVC (or SVC) filters
Mechanical Catheter
embolectomy
Catheter based
thrombolysis
Surgical
embolectomy
Edlow, JA. Emergency Department Management of Pulmonary Embolism. Emergency
Medicine Clinics of North America 19(4). 2001
37
Eduardo Borquez
Gillian Lieberman, MD
Radiologic Treatment
z Catheter
Embolectomy
– Vacuum-cup catheter technique
– Rheolytic embolectomy catheter
(Angiojet embolectomy system)
– Direct, intraembolic, low dose thrombolytic
infusion.
z Filters
Thompson BT, Hales, CA UpToDate Clinical manifestations of and diagnostic strategies for acute
pulmonary embolism http://www.utdol.com
Tapson, VF, UpToDate Massive pulmonary embolism http://www.utdol.com
38
Eduardo Borquez
Gillian Lieberman, MD
Rheolytic Embolectomy Catheter
z Angiojet
zhttp://www.wfubmc.edu/interneuro/techpg1.html
zhttp://www.possis.com/products/new_xmi/open.html
39
Eduardo Borquez
Gillian Lieberman, MD
Greenfield Filter
IVC filter
BIDMC PACS
40
Eduardo Borquez
Gillian Lieberman, MD
Summary
Incidence
Common
Etiology
DVT of lower extremities
Signs/Sx
Varied and nonspecific, but include dyspnea, pain, cough,
tachypnea, tachycardia, crackles
Diagnosis
Complex. Most often V/Q or CT. Angio is gold standard.
Pathology
↓Flow Æ↑ pressure, ischemia.
Surgery/Tx Thrombolysis, embolectomy and prevention.
Prognosis
High mortality without treatment
Thompson BT, Hales, CA UpToDate Clinical manifestations of and diagnostic strategies for acute
pulmonary embolism http://www.utdol.com
Tapson, VF, UpToDate Massive pulmonary embolism http://www.utdol.com
Cotran: Robbins Pathologic Basis of Disease, 6th ed., Copyright 1999 W. B. Saunders Company
41
Eduardo Borquez
Gillian Lieberman, MD
Acknowledgments
Gillian Lieberman, MD
z Matthew Spencer, MD
z Dr. Kevin Donohoe
z Pamela Lepkowski
z Our patient S.I.
z Our webmasters Larry Barbaras
and Cara Lyn D’amour
z
zhttp://radiology.bidmc.harvard.edu/education/default.htm
zhttp://home.caregroup.org/departments/radiology/internet/staff/residents.html
42
Eduardo Borquez
Gillian Lieberman, MD
References
● Thompson BT, Hales, CA UpToDate Clinical manifestations of and diagnostic strategies for acute
pulmonary embolism http://www.utdol.com
● Tapson, VF, UpToDate Massive pulmonary embolism http://www.utdol.com
● Cotran: Robbins Pathologic Basis of Disease, 6th ed., Copyright 1999 W. B. Saunders Company
● Stein, PD et al, Clinical, Laboratory, Roentgenographic and Electrocardiographic findings in patients
with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. Chest 100(3):598.
● Garg, K. CT of Pulmonary Thromboembolic disease. Radiologic Clinics of North America 40(1); 2002
● Felson, B. Gamuts in Radiology. 2nd Edition
● Worsley, DF et al Chest Radiographic Findings in Patients with Acute Pulmonary Embolism:
Observations from the PIOPED Study. Radiology 189:133-136. 1993
● PIOPED Investigators. Value of the Ventilation/Perfusion Scan in Acute Pulmonary Embolism. JAMA
263(20):2753. 1990
● http://www9.biostr.washington.edu/da.html
● Edlow, JA. Emergency Department Management of Pulmonary Embolism. Emergency Medicine
Clinics of North America 19(4). 2001
● http://www.wfubmc.edu/interneuro/techpg1.html
43